Contents

Abbreviations and Acronyms

Executive Summary

Figures

Tables

SECTION 1 REGIONAL HEALTH OVERVIEW

1.1 Demographics

1.1.1 The Caribbean Region 1.1.1.1 Demographic overview of CARPHA Member States

1.1.2 Migration

1.2 Socio-Economic Profile

1.2.1 Gross Domestic Product (GDP) Per Capita 1.2.2 Health Expenditure Data for CARPHA Member States

1.3 Mortality – leading causes of death

1.3.1 Leading Causes of Death in CARPHA Member States (CMS) 1.3.2 Conditions causing death in the English and Dutch -speaking Caribbean, 2000-2012 1.3.3 Conditions causing death in Haiti 1.3.4 Challenges and Limitations 1.3.5 CARPHA’s Role

SECTION 2 COMMUNICABLE DISEASES

2.1 Diseases of Endemic Potential

2.1.1 Vector Borne Diseases 2.1.1.1 Chikungunya 2.1.1.2 Dengue 2.1.1.3 Malaria 2.1.1.4 Leptospirosis

2.1.2 Vector borne Disease Control 2.1.3 CARPHA Recommendations and Role in Controlling Vector Borne Diseases

2.2 Foodborne Diseases

2.2.1 Food security, Food safety and Foodborne Diseases 2.2.2 Food safety and Foodborne Diseases Surveillance in the Caribbean 2.2.3 Foodborne Disease Trends, Caribbean, 2005-2012

2.2.3.1 Salmonellosis in the Caribbean, 2005-2012 2.2.3.2 Salmonella Serotype Trends 2.2.3.3 Ciguatera (fish toxin) poisoning 2.2.3.4 Shigellosis and Campylobacteriosis 2.2.3.5 Norovirus

2.2.4 Conclusions and Recommendations 2.2.5 Limits/Challenges

2.2.6 CARPHA’s role

2.3 Respiratory Viral Illness

2.3.1 Background 2.3.2 Data Trends

2.3.2.1 Acute Respiratory Illness 2.3.2.2 Severe Acute Respiratory Illness 2.3.2.3 Respiratory Virus Trends 2.3.2.4 Emerging Respiratory Viruses

2.3.3 Prevention and Control Strategies 2.3.4 CARPHA Regional Role 2.3.5 Plans for Action and Future Challenges

2.4 Immunization

2.4.1 Overview of the Immunization Program 2.4.2 Rash and Fever Surveillance in the Caribbean and the role of CARPHA 2.4.3 Polio coverage and Acute Flaccid Paralysis (AFP) Surveillance in the Caribbean

2.5 HIV/AIDS in the Caribbean Region

2.5.1 The Regional HIV Response 2.5.2 Epidemiology 2.5.3 Situation in the Caribbean Region

2.5.3.1 Preventing mother to child transmission (pMTCT) 2.5.3.2 Stigma and discrimination 2.5.3.3 Voluntary Testing and Counselling 2.5.3.4 Role of laboratories in universal access to healthcare

2.5.4 Conclusions and Recommendations

2.6 Tuberculosis in the Caribbean*

2.6.1 Introduction 2.6.2 The burden of tuberculosis in The Caribbean

2.6.2.1 Incidence 2.6.2.2 Prevalence 2.6.2.3 Mortality 2.6.2.4 Drug resistant Tuberculosis 2.6.2.5 TB and HIV coinfection

2.6.3 Sustainable development and the post-2015 TB strategy 2.6.4 Challenges to decrease the burden of TB

2.6.4.1 Opportunities for new initiatives 2.6.4.2 The Global Fund support to Human Rights 2.6.4.3 Preventive treatment of the population infected by Mycobacterium tuberculosis

2.7 Outbreaks

2.7.1 Pandemic Influenza 2.7.2 Cholera 2.7.3 Chikungunya 2.7.4 Regional Outcomes and Next Steps

SECTION 3 NON COMMUNICABLE DISEASES

3.1 Mortality

3.1.1 Premature Mortality 3.1.2 Risk Factors for Chronic Diseases 3.1.3 Tobacco use 3.1.4 Physical inactivity 3.1.5 Alcohol consumption 3.1.6 Unhealthy diets 3.1.7 Obesity and overweight

3.1.7.1 Abdominal Obesity 3.1.8 Raised Blood pressure 3.1.9 Combined Risk Factors for Chronic Diseases 3.1.10 Challenges to NCD Prevention and Control in the Caribbean 3.1.11 CARPHA’s Role

3.2 Nutrition

3.2.1 Description and analysis of the current nutritional status in the region 3.2.2 Obesity 3.2.3 Undernutrition and Vulnerable Households 3.2.4 Physical Activity 3.2.5 Iron deficiency anaemia 3.2.6 Breastfeeding 3.2.7 Low Birth Weight (LBW) 3.2.8 HIV/AIDS 3.2.9 Progress and gaps in attaining Regional Health goals/objectives 3.2.10 CARPHA’s Role Appendices

3.3 Chronic Obstructive Pulmonary Disease

3.4 Mental Health

3.5 Violence and Injury Prevention

3.5.1 Overview of Mortality due to Injuries and Violence in CMS 3.5.2 Road Traffic Injuries 3.5.3 Drowning 3.5.4 Self-Inflicted Injuries 3.5.5 Violence 3.5.6 Morbidity from Violence and Injury 3.5.7 Jamaica Injury Surveillance System (JISS) Report 3.5.8 Interpersonal Violence Studies 3.5.9 Violence against Women 3.5.10 Consequences of Injury and Violence 3.5.11 VIP initiatives in the region 3.5.12 Current challenges/ limitations 3.5.13 CARPHA’s Role going forward 3.5.14 Conclusion

SECTION 4 ENVIRONMENTAL HEALTH AND SUSTAINABLE DEVELOPMENT

4.1 Overview

4.2 Key regional and international natural resources management frameworks

4.2.1 Regional frameworks 4.2.2 Global frameworks

4.3 Situational analysis and strategic responses

4.3.1 Water and Wastewater Management 4.3.2 Solid Waste Management 4.3.3 Chemicals and Hazardous Materials Management 4.3.4 Air Quality Management

4.3.4.1 The strategic response to improved Air Quality Management 4.3.5 Strategic Recommendations for CARPHA’s support

SECTION 5 HEALTH INFORMATION SYSTEMS

5.1 Data Quality

5.2 Data Reporting

5.2.1 Reporting of communicable diseases 5.2.2 Reporting of non-communicable diseases 5.2.3 Reporting of Mortality Data

5.3 Medical Laboratories

5.3.1 The role and need for comprehensive, quality laboratory services 5.3.2 Overview of Laboratory Services and Networks in the Caribbean 5.3.3 Challenges and opportunities

5.4 Medicines Regulation

5.4.1 Medicines Policies 5.4.2 Legislation and Regulatory Framework 5.4.3 Human Resources for Medicines Regulation 5.4.4 Licensing Activities

5.4.4.1 Product Assessment and Registration 5.4.4.2 Quality Control

5.4.5 PAHO Pharmaceutical Situation in the Caribbean Report 5.4.5.1 Medicines Policies 5.4.5.2 Licensing 5.4.5.3 Pharmacovigilance 5.4.5.4 Regional Performance in Medicines Regulation

5.4.6 Improving regulatory capacity 5.4.6.1 CCH III Progress 5.4.6.2 Caribbean Pharmaceutical Policy designed and implemented 5.4.6.3 Harmonised medicines supply systems and sub-regional negotiation mechanism 5.4.6.4 Caribbean strategy for rational use of medicines approved and implemented

5.4.7 Future Directions

5.5 Research

5.5.1 Background 5.5.1 National Health Research Systems 5.5.3 Current Status of Regional Health Research Systems

5.5.1.1 Health Research Policy 5.5.1.2 Health Research Agenda for the Caribbean 5.5.1.3 Essential National Health Research Councils/Committees 5.5.1.4 Research Ethics Committees (REC) 5.5.1.5 CARPHA’S Research Ethics Committees

5.5.4 Financing Research 5.5.4.1 CARPHA’s Research Grants Programme

5.5.5 Creating and Sustaining Resources 5.5.5.1 Health Training Programmes 5.5.5.2 CARPHA’s Capacity Building 5.5.5.3 Tropical Medicine Research Institute (TMRI)

5.5.6 Producing and Using Research 5.5.6.1 CARPHA Annual Research Conference 5.5.6.2 Research Outputs of Regional and Academic Research Institutions 5.5.6.3 Caribbean Cochrane Collaboration 5.5.6.4 Evidence-Informed Policy Network (EVIPNet) 5.5.6.5 Clinical Guidelines

5.6 Health Communication

5.6.1 Health Communication in the Caribbean Region 5.6.2 Investments in Health Communications and/or Health Promotion in the Region

5.6.2.1 Key Achievements and Successes 5.6.2.2 Challenges facing the Region 5.6.2.3 The Way Forward

5.7 Human Resources for Health

5.7.1 Introduction 5.7.2 Plans/Planned activities

5.8 Health Financing in the Caribbean

5.8.1 Introduction 5.8.2 Health, Development and Political Commitment to Universal Health Coverage (UHC)

5.8.3 Patterns and Magnitudes of Health Financing in the Caribbean 5.8.4 Health Spending by Programmes 5.8.5 Challenges facing Health Financing Systems in the Caribbean 5.8.6 Health Financing for the Caribbean– The Vision and the Philosophy

5.8.6.1 Sources and Context of Health Financing 5.8.6.2 The Caribbean Environment 5.8.6.3 Philosophy of Health Financing

5.9 Monitoring and Evaluation for Public Health in the Caribbean

5.9.1 Human Resources, Partnerships and Planning 5.9.1.1 Component 1: Organisational Structures with M&E Functions 5.9.1.2 Component 2: Human Capacity for M&E 5.9.1.3 Component 3: Partnerships to Plan, Coordinate and Manage the M&E System 5.9.1.4 Component 4: M&E Plan 5.9.1.5 Component 5: Annual, Costed, National M&E Work Plan 5.9.1.6 Component 6: Communication, Advocacy and Culture for M&E

5.9.2 Data Collection, Verification and Analysis 5.9.2.1 Component 7: Routine Programme Monitoring 5.9.2.2 Component 8: Surveys and Surveillance 5.9.2.3 Component 9: National and Sub-National Databases 5.9.2.4 Component 10: Supportive Supervision and Data Auditing 5.9.2.5 Component 11: Evaluation and Research Agenda

5.9.3 Data Dissemination and Use 5.9.3.1 Component 12: Data Dissemination and Use

SECTION 6 INITIATIVES

6.1 Tourism Migration and Health

6.1.1 Stay-Over (Air Travel) Arrivals 6.1.2 Cruise Ship Arrivals 6.1.3 Suspected spread of chikungunya in 2013 though intra and interregional travel

STATE OF PUBLIC HEALTH IN THE CARIBBEAN

Executive Summary

Environment and Climate Change

Family and Community Health

Behavioural risks

Ageing